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Neck pain is a common cause for presentation to an emergency department. Most causes are benign and often secondary to arthritis or injuries. We present a case of septic cervical facet arthritis, a very rare cause of neck pain. The clinical presentation of septic cervical facet arthritis includes fever, neck pain that is often unilateral that is worse with movement, nerve root symptoms, and radiation of pain to the shoulder. Consequences may be severe and include joint destruction and infection progression. Symptoms may be indolent, and a high index of suspicion is necessary to make this diagnosis. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The objective of the study was to compare errors in the emergency department (ED) with pharmacists present (PPs) for resuscitations and traumas vs with pharmacists absent (PAs). Our hypothesis was that errors would be significantly fewer during PP than PA times. We also hypothesized that times with PP would affect patients greater when disposition was to more critical areas (intensive care unit, or ICUs). Methods: The study was conducted during a 3-month period in 2009 in a level 1 trauma center with an emergency medicine residency. This was a cross-sectional cohort study comparing a prospective analysis of patients during the time (10 hour/day) with PP and a retrospective review of the time on the same days (14 hours/day) with PA. Demographics of age, race, and sex were recorded. Patient disposition was either ICU, operating room, non-ICU wards, observation unit, or discharge. Main outcome was errors recorded including medications given but not ordered, medication ordered but not given, and time delays for medications. For demographics and prevalence, descriptive statistics and percentages were used. Percent differences and 95% confidence intervals (CIs) and χ 2 were derived. Logistic regression used predictor variables of age, race, sex, disposition, and presence or absence of pharmacists. An a priori power analysis was performed. The study was powered at 80% with 186 subjects per group (PP vs PA), to find a difference of 20% between the 2 groups in percent of medical errors. Results: There were 694 patients included in the 3-month period. A total of 242 presented during PP times and 452 during PA times. There were 383 (55%) male, 301 (43%) female, and 10 (2%) unknown sex. Mean age was 45 ± 18 years in PP group and 48 ± 20 years in PA group (P, nonsignificant). There was no difference in ethnicity between groups. There were 6 (3%) patients with errors recorded during PP times and 137 (30%) with errors recorded during PA times (difference, 27%; 95% CI, 23-32). Controlling for age, race, sex, and disposition, medical errors were 13.5 times more likely during PA than during PP times (adjusted odds ratio, 13.5; 95% CI, 5.7-31.9). Conclusion: With pharmacists absent, over 13 times more errors are recorded in our ED than with pharmacists present. An on-site pharmacist in the ED may be helpful in reducing medical errors. [Copyright &y& Elsevier]

Abstract: Introduction: Emergency medical services (EMS) personnel attrition is a serious concern. Two fundamental psychological constructs linked to attrition are organizational and occupational commitment. Objective: To determine if there is a relationship between a paramedic''s degree of occupational/organizational commitment and the following: (1) levels of education and (2) type of employment. Methods: This was a cross-sectional study of paramedics in 6 states that require continued paramedic national registration. The data collection instrument consisted of demographic and occupational and organizational commitment sections. For level of education, the primary independent variable, each subject was placed into 1 of 3 groups: (1) certificate, (2) associate''s or bachelor''s degree in EMS (degree), and (3) paramedic certificate or degree with a non-EMS postbaccalaureate degree. Type of employment (fire based vs non–fire based) was also used as an independent variable. Organizational and occupational commitment was measured using validated scales for each. Analysis of variance was used for the comparisons between levels of each of the independent variables. A P < .05 was considered significant. Results: For occupational commitment, the participants with certificate level of education had a significantly higher score (88.9) than did those with either the degree (83.6) or postbaccalaureate (80.9) level of education. There were no significant differences for total organizational commitment. There were also no overall differences in occupational and organizational commitment between fire- and non–fire-based employees. Conclusion: Paramedic occupational commitment shows a statistically significant decrease with increased level of education. Factors associated with commitment of more highly educated paramedics need to be explored. [Copyright &y& Elsevier]

Abstract: Background: In a previous study, no association was found between intimate partner violence (IPV) victims and being an adult who witnessed IPV as a child (ACW). Objective: The objective of the present study was to determine whether perpetrators of IPV (Perps) could be identified in a busy emergency department (ED) and whether Perps were more likely than non-Perps to be ACWs. The hypothesis was that Perps differed significantly from non-Perps in being ACWs, in being victims of IPV, and in demographics. Methods: The design was a cross-sectional cohort of patients presenting to an academic ED during randomized 4-hour shifts. A choice of computer touch screen data vs paper format was offered. Data collected included demographics as well as scales to determine whether subjects were a Perp, victim, and/or ACW of IPV. Six validated scales were used to screen and confirm victims, Perps, and ACWs. Predictor variables were ACW, ongoing IPV, and demographics. Results: Two hundred thirty-six subjects were entered, 207 had complete data sets. Forty-four (19%) were Perps. By univariate analysis, there was a significant correlation of Perps and ACW (P = .001 by single question) and between Perp and being victims (P = .001). No other univariate variables were significantly correlated. By regression analysis, significant predictors of Perp included ACW and spouse drug abuse. Conclusions: The Perps were identified in a busy ED setting. Perps were significantly more likely than non-Perps to be ACWs, but not more likely to be victims. Spouse drug abuse and ACW were the 2 significant predictors of Perp. [Copyright &y& Elsevier]

Objective. We attempted to identify psychological comorbidities that are associated with the propensity for prescription opioid abuse. Interventions. Patients presenting to an emergency department seeking opioid refills for chronic pain were evaluated with five validated self-report instruments and structured clinical interviews. The potential for prescription opioid abuse was modeled with multiple regression analysis using depression, anxiety disorders, personality disorder, and addiction as independent variables. Results. Of the 113 patients studied, 91 (81%) showed a propensity for prescription opioid abuse as determined by scores on the Screener and Opioid Assessment for Patients with Pain instrument. Depression, anxiety, and a history of substance were common and panic attacks, posttraumatic stress disorder, and personality disorders were also found, albeit less frequently. Panic attacks, trait anxiety, and the presence of a personality disorder accounted for 38% of the variance in the potential for prescription opioid abuse. Conclusions. Patients in chronic pain should be assessed for psychological and addiction disorders because they are at increased risk for abusing opioids. They should also be referred for psychosocial treatment as part of their care, where appropriate. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To evaluate compliance and safety of an emergency medical service (EMS) triage protocol that allows paramedics to transport patients directly to psychiatric emergency services. Methods: A psychiatric patient diversion protocol was developed for our system. Protocol compliance was evaluated the following 3 ways: (1) psychiatric facility intake forms completed by mental health workers on patients transported by EMS directly to a psychiatric emergency service (PES) bypassing the ED, (2) hospital records for patients who were redirected from PES to the ED for medical evaluation, (3) retrospective analysis of ambulance charts. Study outcomes included protocol noncompliance rate, protocol failure rate, and any morbidity associated with either noncompliance or protocol failure. Data were analyzed using proportions and 95% confidence intervals (CI). Results: A total of 174 patients were directly transported to PES bypassing ED medical clearance. The protocol effectively screened for medical issues in 96% of cases. Protocol noncompliance occurred in 51 cases for a frequency of 29% (CI, 22%-36%). One patient in the paramedic noncompliance group required hospital admission. There was protocol failure in 5 (2.9%; 95% CI, 0.9-6.6) of the patients who fit all protocol requirements for transport to PES but required secondary transport to the ED. All were subsequently transferred back to PES. Nine patients (5.2%; CI, 2.7%-9.5%) required secondary transfer to the ED. No patient had critical or life-threatening problems. Conclusions: Emergency medical service providers showed a poor level of compliance with vital sign criteria, but the protocol provided a high level of safety. [Copyright &y& Elsevier]

Abstract: Introduction: Ambulance diversion is a problem in many communities. When patients are diverted prompt and appropriate medical care may be delayed. Objective: Compare diversion hours and drop-off times before and after a dramatic change in diversion policy restricting each hospital to 1 hour out of every 8. Methods: This study was a retrospective study in a county of 600000 people and 10 hospitals from September 2004 to February 2006. A countywide diversion protocol was implemented in March 2005 that limited diversion hours to 1 hour out of every 8 (maximum of 90 h/mo). No other changes were implemented during the study period. Pretrial (9/04-2/05), interim (3/05-8/05), and posttrial (9/05-2/06) periods were compared. The main outcome measures were ambulance diversion hours and emergency medical service (EMS) drop-off times. Results were compared using analysis of variance and a Tukey post hoc analysis. P < .05 was considered significant. Results: There was no significant difference in the number of monthly transports comparing the posttrial vs pretrial periods; however, a significant decrease in monthly ambulance diversion hours (difference, 251 hours; 95% CI, 136-368) and significant increase in additional time that EMS crews required to transport patients (drop-off times) (difference, 178 hours; 95% CI, 74-283) were observed. Posttrial diversion hours decreased to 18% of the pretrial values (from 305 to 54). Conclusion: This novel ambulance diversion protocol dramatically reduced diversion hours at the cost of increasing EMS drop-off times in a large community. [Copyright &y& Elsevier]

Abstract: Objectives: Our objectives were (1) to determine demographic characteristics of intimate partner violence (IPV) victims and perpetrators, as reported by victims in a Victim Assistance Unit where police are called to the scene for IPV, and (2) to compare the relative risk of methamphetamine, cocaine, and alcohol use in perpetrators vs victims of IPV, as reported by victims. Methods: Data from a Victim Assistance Unit intake statistics for the months of January to November 2006 were accessed. For this system in a city of approximately 500 000 population, with a large Hispanic population, police call for an onsite advocate intervention (trained social worker) at their own discretion for the victim and for children involved. Data were collected from the homes visited by police for IPV calls based on victim report on victims, perpetrators, and children in the home and their involvement in IPV. Reports of drug use were self-reported by the victim only. Comparisons were made using χ 2 tests, relative risks (RRs), and 95% confidence intervals (CIs). P < .05 was considered statistically significant. Results: Police and advocates visited 1712 homes for IPV calls; males were victims in 141 (8.2%) cases. Nine hundred ninety-seven (58.2%) victims were Hispanic. By victim report, perpetrators were significantly more likely to have witnessed IPV as a child than victims did (48.8% vs 34.3%; RR, 1.4; 95% CI, 1.3-1.6). Of the 2266 children in these homes, 1800 (79.2%) witnessed IPV and 716 (31.6%) were victims themselves. By victim report, the perpetrators were significantly more likely to use methamphetamine (8.9% vs 0.8%; RR, 10.9; 95% CI, 6.4-18.8 ), cocaine (11.8% vs 0.7%; RR, 16.8), and alcohol (53.3% vs 12.9%; RR, 4.1; 95% CI, 3.6-4.7) than victims. Conclusion: By victim report, perpetrators were more likely to have witnessed IPV as children. By victim report, perpetrators were also more likely to use methamphetamine, cocaine, and alcohol and other drugs. Knowing this correlation may be important to the emergency department physician as screening for drug use, especially methamphetamine, as well as IPV may be useful to identify IPV-related injuries and provide proper referrals for IPV and drug use treatment. [Copyright &y& Elsevier]

Abstract: Objective: Children who witness intimate partner violence (IPV) experience many psychological and social problems similar to those of the victimized parent. Intervention programs for children who witness IPV have not been adequately evaluated. Two of the most important target areas in treating the children are to improve understanding that (1) the violence is not their fault and that (2) development of a safety plan is valuable in case of future violence. We evaluated a unique immediate and ongoing intervention program for children who witness adult IPV. Methods: This was a retrospective review of progress report results both pre- and postintervention of an ongoing IPV intervention program. Population and Intervention: The study was completed in a largely Hispanic city of 500000. The intervention program included a number of unique aspects including immediate intervention at the time of police calls for adult IPV, children''s art therapy and sand tray therapy, and a unique coloring book to establish a child safety plan in the event of recurrent IPV. Progress report forms included 16 qualitative questions that evaluated the child''s understanding of various important concepts pre- and postintervention. Inclusion: All children who entered the program in the last 3 years and had completed data sets for all 16 questions were included. Responses to questions pre- vs postintervention were compared using Wilcoxon signed ranks test. Results: Fifty-eight children had complete data sets pre- and postintervention. Mean age was 8.5 ± 3.5 years (range, 3-17), and 49% were male. Mean length of therapy was 7.4 ± 5.2 months (range, 1-31), with a mean number of sessions of 9.7 ± 11.7 (range, 1-59). For 15 of the 16 evaluation questions, a statistically significant improvement in postintervention evaluations compared with preintervention evaluations was found (P < .01). This included a significant improvement in the percentage of children who were aware that violence was not their fault (59% preintervention vs 84% postintervention; difference, 25%; 95% confidence interval, 9-41) and a significant improvement in the percentage of children who knew and understood a safety plan in case of recurrent episodes of violence exposure (32% preintervention vs 93% postintervention; difference, 61%; 95% confidence interval, 47-75). Conclusions: Among children who were exposed to adult IPV and subsequently underwent immediate and ongoing treatment, there was a significant improvement in the percentage of children who were aware that violence was not their fault and in the percentage of children who were aware of safety planning. [Copyright &y& Elsevier]

Objective. We hypothesized that the assaults on EMS personnel by patients requiring restraints can be correlated with demographic information, patient condition, and other scene information such as presence the of law enforcement. Methods. The study was a one-year cross-sectional study of paramedic restraint use and assault on EMS personnel in an urban area. A data collection form was completed by EMS for each patient placed in restraints. Study outcome variable was “Assault on EMS personnel.” Predictor variables included demographic and EMS call information, patient condition, law-enforcement related variables, and the paramedic's perception of the need for chemical restraints. To compare predictor and outcome variables, a multivariable model with odds ratios and 95% confidence intervals was used. Results. The study included 271 restrained patients over a 12-month period from April 2002 to April 2003. Seventy-seven (28%) cases were positive for assaults on EMS personnel. Multivariable analysis including 8 variables, indicated the following 6 variables were associated with assault on EMS personnel: time of day between midnight and 6 am (OR = 4.4, 95% CI = 1.6–12.7); female patient (OR for males 0.6, 95% CI = 0.3–1.0); violent patient (OR = 10.1, 95%CI = 2.3–48.2); patient injured under supervision (OR = 3.9, 95% CI = 1.1–13.8); arrested patient (OR = 4.4, 95% CI = 1.1–18.5); and perceived need for chemical restraint (OR = 2.1, 95% CI = 1.2–3.9). Conclusion. Multiple factors are correlated with assaults on EMS personnel by patients requiring restraints. By specifically targeting patients exhibiting these factors, EMS providers can help prevent injury to themselves. Patients not exhibiting these factors may be less dangerous. [ABSTRACT FROM AUTHOR]